Basic Information
Provider Information | |||||||||
NPI: | 1124051099 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.R.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | PRINCE FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 206784017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104144791 | ||||||||
FaxNumber: | 4104144556 | ||||||||
Practice Location | |||||||||
Address1: | 14090 HG TRUEMAN RD STE 2100 | ||||||||
Address2: |   | ||||||||
City: | SOLOMONS | ||||||||
State: | MD | ||||||||
PostalCode: | 206883151 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103943712 | ||||||||
FaxNumber: | 4103943714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R134606 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 003982900 | 05 | MD |   | MEDICAID | 64804501 | 01 | MD | CAREFIRST BCBS | OTHER | 13070005 | 01 | DC | CAREFIRST BCBS OF DC | OTHER |